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2013 Survey of regiStered nurSeSGeneration Gap Grows as HealtHcare transforms

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IN THIS REPORT

INtroDuctIoN

Key fINDINgS

MetHoDology

cAreer SAtISfActIoN

HourS worKeD

geNerAtIoNAl DIffereNceS

coNcluSIoN

DeMogrApHIcS

pAge 2-3

pAge 4

pAge 4

pAge 5-7

pAge 8

pAge 8-15

pAge 16-17

pAge 19-22

2013 Survey of regiStered nurSeSGeneration Gap Grows as HealtHcare transforms

© AMN Healthcare, Inc. 2013www.amnhealthcare.com

For additional information about this survey or other surveys conducted by AMN Healthcare and its family of companies, please contact: wendy.newman@amnhealthcare.com

AMN Healthcare 12400 High Bluff Drive San Diego, CA 92130}

INTroDuCTIoN

the dramatic transformation created by healthcare reform and other pressures, coupled with economic recovery and demand for a variety of clinicians, has created a dynamic scenario for nursing employment where attitudes and career outlooks of younger, mid-career and older nurses appear to be headed in different directions. though nurses of all ages are very satisfied with the choice of their careers, they view the overall state of nursing today and the near future for their jobs very differently.

this survey explores projected career paths, satisfaction levels and other professional aspects of nursing through the candid expression of concerns and plans of a wide strata of registered nurses (rNs). In revealing generational differences in nursing careers and other critical information about the nursing profession directly from nurses themselves, the survey provides valuable information to healthcare leaders for planning future nurse staffing. the results from this study also are offered as an information resource for healthcare industry leaders, policy-makers, academics, staffing professionals, analysts and others who follow clinical staffing and supply trends.

the 2013 Survey of registered Nurses provides demographic information on nurses’ near- and long-term plans for their careers, including retirement, seeking advanced degrees and certifications, working part-time or leaving the field altogether. Nurses were also queried on their views about electronic medical records, quality of patient care, career satisfaction and the nursing shortage.

2

recently gathered information on the nursing workforce presents a picture of the future that is somewhat mixed but overall generally positive:

Nursing is the largest healthcare profession, with more than 3.1 million rNs nationwide. Approximately 2.6 million rNs are employed as nurses, meaning that 500,000 licensed nurses do not work in the nursing field. (u.S. Department of Health and Human Services, “the registered Nurse population: findings from the 2008 National Sample Survey of registered Nurses,” September 2010.) Nurses working in clinical settings represent more than half of all labor costs in acute care settings.

Issues of supply, demand and future shortages of nurses are currently in question. An April 2013 “perspective” article in the New England Journal of Medicine asserted that improvements in nursing education and rising levels of nursing school graduations could dramatically alter projected nursing shortages, even perhaps eliminating them. (David Auerbach, phD, “the Nursing workforce in an era of Health care reform”)

However, the same article acknowledges that the level of future demand for rNs is unknown. So, whether the improving outlook for nurse education will provide an adequate future supply of nurses also is unknown.

research and staffing data show continued shortages and growing demand for advanced practice nurses.

the future outlook for rN employment remains strong, despite recent job losses in healthcare caused by automatic federal spending cuts, or sequestration, and reductions in hospital patient volume caused by healthcare reform and higher deductible insurance policies.

employment of rNs is growing faster than the average for all occupations, projected to rise 26% from 2010 to 2020. (uS Department of labor, Bureau of labor Statistics, occupational outlook Handbook)

the 2013 Survey of registered Nurses by AMN Healthcare was conducted during a time of optimism but also uncertainty for the healthcare workforce, and that conflict is reflected in many of the survey responses, particularly in the differences between older and younger nurses.

3

Key FINDINGS

Nearly 190,000 nurses could leave nursing or retire now that the economy is recovering.

twenty-three percent of nurses age 55 and older will change their work dramatically, including opting for retirement or leaving the nursing field for other types of work.

younger nurses are much more positive about the quality of nursing today. when asked to respond to the statement, “Nursing care has generally declined,” 37% of nurses age 19-39 agreed compared to 66% for nurses age 55 and older.

younger nurses are much more likely to agree that electronic medical records positively influence job satisfaction, productivity, time management and the quality of patient care.

Despite recommendations from the landmark Institute of Medicine (IoM) report on the future of nursing (“the future of Nursing: leading change, Advancing Health” 2011), less than half of rNs with an associate degree or diploma will pursue additional education in nursing; however, younger and mid-career nurses are more likely to pursue advanced education in nursing.

About 40 percent of nurses age 19-39 plans to pursue a master’s degree in nursing or higher degree.

Nurses of all ages are very satisfied with the choice of their careers.

MeTHoDoloGy

the 2013 Survey of registered Nurses was the fourth annual survey conducted by AMN Healthcare. Questionnaires were delivered and returned during April 2013.

the AMN Healthcare portal websites, NurseZone.com and rN.com, were the source of e-mail addresses for those opted-in members. Statistical analyses were run with a 95% confidence threshold.

A total of 101,431 surveys were sent via e-mail, to which there were 3,413 responses. the response rate was 3.36%.

4

younger nurses are much more likely to agree that electric medical records positively influence job satisfaction, productivity, time management and the quality of patient care.

5

SpecialtieS agreeing with the Statement: “Overall, i am SatiSfied with my chOice Of nurSing aS a career”

NursINg specIAlty

Or/pAcu 93%

Female

Male

90%

84%

89%

89%

91%

Age 19-39

Age 40-54

Age 55+

Medical/surgical 89%

Home Health/Hospice 88%

Management 93%

pediatrics/ pIcu 91%

school Nurse 96%

Other 91%

er/trauma 89%

Women’s Health/ l&D 91%

critical care 87%

psychiatry 82%

geriatrics/ltc 86%

NIcu/Neonatal 82%

telemetry/pcu 83%Oncology 95%

rehab 91%

education 95%

CAreer SATISFACTIoN

Several years of AMN Healthcare rN surveys have shown that nurses are very satisfied with their choice of career, and in 2013 those high satisfaction levels continue. Approximately 90% of nurses stated they are satisfied with their career choice. that number is virtually identical for all age groups and remains stable across education levels and in most specialties, although the satisfaction level is lower in a few specialties. Nurses in psychiatry and neo-natal intensive care reported an 82% career choice satisfaction rate, while those in telemetry, geriatrics and home health/hospice reported 83%, 86% and 88%, respectively. However, many surveys show that job satisfaction among registered nurses generally ranks high among employment categories.

Approximately 90% of nurses stated they are satisfied with their career choice. That number is virtually identical for all age groups and remains stable across education levels and in most specialties.

6

Despite the high level of career choice satisfaction, nurses are less sanguine about their current jobs – only 73% said they are satisfied with them. when asked if they would encourage others to become a nurse, 72% answered affirmatively. Meanwhile, 51% said they worry that their jobs are affecting their health. thirty-five percent said they often feel like resigning, while 33% said that if they had their way, they would not be working in their current job a year from now. the highest levels of those who said they would not be working in their current jobs in one year were 41% of nurses in psychiatry, 38% in geriatrics and 37% in critical care and medical/surgical.

career choice and current job satisfaction are similar across age ranges of nurses, with a few notable exceptions. when asked if they would encourage others to become nurses, 80% of nurses age 19-39 said they would, while 73% of nurses age 40-54 and 70% of nurses age 55 and older replied affirmatively. In answer to the statement, “I often feel like resigning from my position,” 36% of nurses age 40 and older agreed compared to 28% of nurses age 19-39. Also, 34% of nurses age 55 and older, 33% age 40-54 and 29% age 19-39 said that if they had their way, they would not be working in the same job a year from now.

7

1. or

2. Critical Care

3. Med-Surg

20% 40% 60% 80% 100%0%

won’t be working in current job in a year

Often feel like resigning from job

have the time needed to spend with patients

worry job is affecting health

will encourage others to become a nurse

Satisfied with current job

Satisfied with quality of care

Satisfied with career

2010

2011

2012

2013

Overall, rnS are very SatiSfied with career chOice but leSS with current jOb

Specialties with more than 30% of RNs indicating they intend on leaving their current job in the next year:

Males are more likely than

females to leave their job in

the coming year.

4. er

5. Telemetry

6. Geriatrics

7. Psychiatry

8. Home health

9. rehab

8

HourS WorKeD

Nurses continue to work longer hours. the average work week for full-time nurses who responded to the survey is approximately 42 hours a week. More than 30% of nurses work more than 40 hours a week, while 13% of respondents said they work 46-50 hours a week and 8% work more than 50 hours a week.

when the average number of hours worked each week is viewed by age group, younger nurses tend to work a standard work week compared to older nurses. Among nurses age 19-39, 60% work 36-40 hours per week, compared to 53% for nurses age 40-54 and 47% for nurses 55 and older. older nurses tend to have more varied work weeks compared to younger nurses. for example, 4% of nurses age 55 and older work less than 10 hours a week, compared to 2% for nurses age 19-39, and 11% of nurses age 55 and older work 46-50 hours per week, compared to 8% for nurses age 19-39.

when it comes to working long hours, 12% of male nurses work more than 50 hours per week, compared to 6% of female nurses.

GeNerATIoNAl DIFFereNCeS

Similar to the generational differences regarding job satisfaction, younger nurses are generally more confident about the nursing profession, their own careers, the quality of patient care, the benefit of electronic medical records, as well as other factors related to nursing. Some of the responses from younger nurses regarding future career plans are to be expected, considering that they have more time ahead of them before retirement. other responses may reflect knowledge gained through experience and generational characteristics regarding technology.

cAreer cHANge

Now that the economy is improving, approximately 23% of nurses age 55 and older plan to dramatically change their work life in the very near future, including 13% who say they will retire, while 3% say they will take a non-nursing job and 7% will work part-time.

In extrapolating this data to the entire rN population, approximately 187,200 nurses will either retire or enter a non-nursing job, while an additional 81,900 will change from full-time to part-time work.

Now that the economy is improving, approximately 23% of nurses age 55 and older plan to dramatically change their work life in the very near future.

9

23% Of nurSeS Over 55 will change their wOrk dramatically

nurses age 55 and over

retirement will impact specialties

continue working

Seek a new full-time nursing job

work part-time

take a non-nursing job

retire

Impact of RN retirements nationwide*:

• 187,200 RNs age 55+ will retire or switchto non-nursing jobs in the near future

• 81,900 will change from full time to part time

*Projected to entire uS working rN population from survey responses

HIgHer eDucAtION

In a landmark 2010 report entitled “the future of Nursing: leading change, Advancing Health,” the Institute of Medicine (IoM) strongly recommended that nurses “should practice to the full extent of their education and training” and “achieve higher levels of education and training,” so they can become full partners with physicians in the era of healthcare reform.

Nearly one-quarter of nurses age 19-39 who responded to the survey said they will pursue a bachelor’s degree in nursing in the next three years, while 34% said they will pursue a master’s degree in nursing. Among nurses age 40-54, 22% said they will seek a bachelor’s degree and 22% a master’s degree. Nurses from several specialties are particularly interested in pursuing higher degrees, most notably: critical care, er/trauma, telemetry, geriatrics, pediatrics, oncology and rehab.

Not surprisingly, younger and mid-career nurses will not retire. In addition, far fewer also said they will reduce the hours they work. In a sign of rising opportunity in the health industry, 20% of nurses age 19-54 said they will seek a new nursing job in the near future. that figure is twice as many as among nurses age 55 and older.

62%15%3%7%13%

0% 10% 20% 30%

labor & delivery

School nurses

psych

geriatrics

management

yOunger nurSeS are mOre likely tO purSue advanced educatiOn in nurSing

10

age 19-39

age 40-54

age 55+

0% 10% 20% 30% 40% 50% 60% 70% 80%

pursue bSn

pursue mSn+

pursue non-nursing degree

won’t pursue education

Specialties with highest numbers not pursuing advanced education at all are:

or = 63%

labor & Delivery = 61%

School nurses = 84%

Specialties most interested in pursuing additional education are:

Critical care = 46%

oncology = 42%

Pediatrics = 43%

11

specIAlty certIFIcAtION Specialty certification follows an expected generational pattern, with nurses age 40-54 and age 55 and older currently certified through professional organizations at rates of 34% and 38%, respectively. only 21% of nurses age 19-39 are certified. the percentages are reversed for nurses who are considering certification within the next one to three years, with 59% of nurses age 19-39 saying that they will seek certification, compared to 41% for those age 40-54 and 23% for those age 55 and older. rNs who hold advanced nursing degrees are more likely to also hold specialty certification.

forty percent of nurses with a diploma, 36% with an associate’s degree and 25% with a bachelor’s degree said they are not considering a certification in the near future.

• 34% of RNs are currently certified

• 36% of RNs are considering certification in the near future

• 30% do not plan on obtaining certification in the future

mOre highly educated rnS are mOre likely tO hOld Specialty certificatiOn

diploma

associate’s

bSn

mSn

doctoral0% 10% 20% 30% 40% 50% 60%

currently certified

will likely certify in near future

will not obtain certification

overall, less than half of rNs with an associate’s degree or a diploma will pursue additional education in nursing. Sixty-five percent of nurses with a diploma and 50% of nurses with an associate’s degree said they will not pursue any further education. Among nurses with a diploma or an associate’s degree, 22% and 34%, respectively, said they would seek a bachelor’s degree. for nurses with a diploma, associate’s degree or bachelor’s degree, a master’s degree is rarely considered while a doctorate is almost never planned, while 34% of nurses with a master’s degree said they would seek a doctorate.

12

age 19-39

age 40-54

age 55+

5

4

3

2

120132012

5

4

3

2

120132012

emr influence On jOb SatiSfactiOn and prOductivity

positively influenced job satisfaction

positively influenced productivity and time managment

Strongly disagree

Strongly agree

disagree

neither agree nor disagree

agree

HeAltH INFOrMAtION tecHNOlOgy the use of electronic medical records (eMr) is also a generational issue. when asked if the use of eMrs at their facility positively influence their job satisfaction, 67% of nurses age 19-39 strongly agreed or agreed, compared to 51% for nurses age 40-54 and 45% for nurses age 55 and older. In response to whether eMrs positively influence productivity and time management, agreement ranged from 60% among younger nurses to 38% among older nurses. regarding whether eMrs positively influence the quality of patient care, nurses age 19-39 answered in the affirmative at a rate nearly 20% higher than nurses age 55 and older.

13

age 19-39

age 40-54

age 55+

20132012

5

4

3

2

1

the uSe Of emr haS pOSitively influenced quality Of patient care

QuAlIty OF NursINg cAre A significant generation gap exists in the belief that the quality of patient care is on the decline and that nursing has become less dynamic and rewarding. when asked to respond to the statement, “Nursing care has generally declined,” 37% of nurses age 19-39 agreed, compared to 56% for nurses age 40-54 and 66% for nurses age 55 and older. In response to the statement, “Nursing is less dynamic, rewarding and robust today than when I began,” 31% of nurses age 19-39 agreed, compared to 47% for nurses age 40-54 and 56% for nurses age 55 and older.

Strongly disagree

Strongly agree

disagree

neither agree nor disagree

agree

14

perceptions about quality of care also differ depending on education level. Among nurses with a doctoral degree, 86% say they are satisfied with the quality of care they provide. for nurses with master’s and bachelor’s degrees, the figure is about 78%, while it is 72% for nurses with an associate’s degree and 76% for those with a diploma.

The results reflect the percent of nurses in various age

groupings that believe that care has declined since they

began as a nurse. over the years of the survey, the belief in

a quality decline has remained stable, albeit at concerning

levels especially among mid-career and older nurses.

age 19-39

age 40-54

age 55+

70

60

50

40

30

20

10

02011 2012 20132010

nurSeS generally believe the quality Of patient care iS cOntinuing tO decline

4541

15

NursINg sHOrtAge younger nurses also have a more confident view of the future supply of qualified nurses. when asked to assess the nursing shortage today compared to five years ago, 45% of nurses age 19-39 said the shortage today is not as bad, compared to 41% of nurses age 40-54 and 34% of nurses age 55 and older. regarding whether healthcare reform will ensure an adequate supply of quality nurses, 38% of nurses age 19-39 were very confident or somewhat confident that it would, compared to 29% of nurses age 40-54 and 27% of nurses age 55 and older.

Nurses from agencies are slightly less confident than permanent staff that the nursing shortage is receding. Among permanent staff, 40% said the shortage is not as bad as five years ago, while only 31% of agency nurses agreed.

45%34%

41%

no change in the shortage

Shortage not as bad

Shortage is worse

0% 50%40%30%20%10%

2011

2012

2013

2010

yOunger nurSeS view Supply Of nurSeS mOre pOSitively than Older nurSeS

believe shortage is not as bad (2013)

age 19-39

age 40-54

age 55+

16

cONclusIONs

generational differences in career plans and attitudes about nursing are pronounced among younger, mid-career and older nurses. Some of those differences are to be expected. for example, nurses who are closer to retirement will naturally have fewer career advancement plans than nurses with several decades of work in front of them. other differences may be ascribed to the years of experience and knowledge in nursing and the healthcare industry – what might be called wisdom vs. idealism. But it cannot be ignored that the level of dissatisfaction grows with years of experience in nursing.

one area of concern must be the significant percentage of nurses age 55 and older – 23% – who are planning to leave the nursing field altogether or make changes that will decrease their level of participation in the profession. combined with the higher levels of dissatisfaction among older nurses, this could result in even greater numbers leaving the profession or reducing their hours, which could have a profound effect on the supply of nurses and quality of care.

the differences among younger, mid-career and older nurses regarding their attitudes on the quality and dynamism of the nursing profession is rather discouraging, considering that 66% of nurses age 55 and older said that nursing care has declined, while only 37% of nurses age 19-39 agree – a clear majority of older nurses vs. a minority of younger ones. Nursing is a stressful occupation, and it is not surprising that decades of toil might produce a weary outlook. the very high levels of career choice satisfaction, however, show that no matter how enervating nursing may become after many years, nurses remain stalwartly proud of their work and their profession.

The notable differences in attitudes and career outlook among younger, mid-career and older nurses highlight areas of dissatisfaction that healthcare leaders must address in nurse recruitment and retention strategies.

the greater acceptance and appreciation for electronic medical records among younger nurses is to be expected, since it’s universally accepted that today’s younger generations seem to have a native understanding of technology that Baby Boomers cannot match. this also may be good news amid the current wave of dissatisfaction over eMrs among all clinicians. Since acceptance of health information technology is greater among younger nurses, the percentage of nurses who appreciate eMrs will continue to grow.

finally, the percentages of nurses who say they will seek higher education are not high enough yet to fulfill the Institute of Medicine’s (IoM) recommendations that higher levels of training and education are necessary. this deficiency cannot be charged entirely to nurses themselves, as IoM recommendations state that schools of nursing, private and public funders, academic leaders and university trustees, and accrediting bodies should undertake the responsibility of increasing the education level of nurses and ensuring lifelong learning in nursing.

17

the following results stand out from the 2013 Survey of registered Nurses:

• Career choice satisfaction remains extremely high among all strata of nurses.

• Approximately 23% of nurses age 55 and older plan to dramatically change theirwork life in the very near future, including 13% who say they will retire.

• A large majority of nurses age 55 and older -- 66% -- believe that nursing care hasgenerally declined, compared to only 37% of nurses age 19-39.

• When asked whether EMRs positively influence the quality of patient care, nursesage 19-39 answered affirmatively at a rate nearly 20% higher than nurses age 55 and older.

• Less than half of RNs with an associate’s degree or a diploma plan to pursue anyadditional education in nursing.

• Nearly one-quarter of nurses age 19-39 will pursue a bachelor’s degree in nursing,while 34% will pursue a master’s degree.

• Only 21% of nurses age 19-39 hold specialty certification. However, 59% of nursesage 19-39 will seek certification, compared to 41% for those age 40-54 and 23% for those age 55 and older.

the notable differentiation of attitudes and career outlook among younger, mid-career and older nurses highlights areas of dissatisfaction that healthcare leaders must address in their nurse recruitment and retention strategies. Innovative workforce solutions could help maintain high standards of patient care and efficiency in the era of healthcare reform and dramatic change in the healthcare industry.

18

DeMOgrApHIcs OF survey respONDeNts

age

40-5419-39

55 and over

15%40%45%

gender

• Average age = 51.5 years

• Employed in acute care = 66%

• Employed full-time = 79%

• Average hours worked per week = 38.4 hours

female

male7%93%

19

type Of wOrk

full-timepart-timeOther

79%6%

15%

60

50

40

30

20

10

010 - 15 16 - 20 21 - 25 26 - 30 31 - 35 36 - 40 41 - 45 46 - 50 50 hours

or more

number Of hOurS wOrked per week

20

Or/pAcu 12%

critical care 10%

psychiatry 4%

Medical/surgical 12%

Management 6%

geriatrics/ltc 4%

er/trauma 8%

telemetry/pcu 5%

Home Health/Hospice 5%

pediatrics/ pIcu 3%

Women’s Health/ l&D 5%

Oncology 3%

NIcu/Neonatal 1%

school Nurse 1%

Other 17%

rehab 2%

education 1%

primary nurSing Specialty

nurSing degree

0% 5% 10% 15% 20% 25% 30% 35% 40%

doctoral degree

master’s degree

bachelor’s degree

associate’s degree

diploma

21

emplOyment Setting

0% 10% 20% 30% 40% 50% 60% 70%

Other

insurance

non-nursing field

not currently employed

nursing home/extended care

physician office/ambulatory care

home health/hospice

hospital

public/community health

nursing education

22

18%

16%

14%

12%

10%

8%

6%

4%

2%

0%1 - 5 6 - 9 10 - 14 15 - 19 20 - 24 25 - 29 30 - 34 35 - 39 40 or

moreless than 1 year

yearS in practice

marital StatuS

now married

widowed

Separated

never married

divorced

64%4%19%2%11%

www.amnhealthcare.com

For additional information about this survey or other surveys conducted by AMN Healthcare and its family of companies, please contact: wendy.newman@amnhealthcare.com

AMN Healthcare 12400 High Bluff Drive San Diego, CA 92130